Provider Demographics
NPI:1780093781
Name:SAMAR DENTAL GROUP
Entity type:Organization
Organization Name:SAMAR DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:COLLAZOS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:786-261-1163
Mailing Address - Street 1:8500 SW 109TH AVE APT 212
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-4458
Mailing Address - Country:US
Mailing Address - Phone:786-261-1163
Mailing Address - Fax:
Practice Address - Street 1:8601 NW 58TH ST UNIT 102
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-3312
Practice Address - Country:US
Practice Address - Phone:786-261-1163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20855261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental